The Third Stage of Labour

Third Stage of Labour by New beginnings student, Verlyndah Hodge

The third stage of labour is defined as that time extending from the birth of the baby until the birth of the placenta. In contrast, a ‘forced birth’, by comparison, is one that is primarily devoid of spontaneity and is contrived to fit the pre-determined expectations of the woman and/or her attendants.

1. What is involved in a normal physiologic third stage?

Medically led care of childbearing women includes the use of active management of the third stage of labour, which include the administration of uterotonic agents [pharmacological agents used to induce contraction or greater tonicity of the uterus], controlled cord traction and uterine massage of the uterus after delivery of the placenta, as appropriate. This process includes the following:

• Within 1min of the birth of the baby, palpate the abdomen to rule out the presence of an additional baby(s) and give oxytocin 10 units IM.
• Keep slight tension on the cord and await a strong uterine contraction (2—3 min) With the strong uterine contraction, encourage the mother to push and very gently pull downward on the cord to deliver the placenta while maintaining counter traction above the pubic bone. As the placenta delivers, hold the placenta in both hands and gently turn it until the membranes are twisted. Slowly pull to complete the delivery.
• Immediately after the placenta is born, massage the fundus of the uterus until the uterus is contracted

However, normal physiologic third stage should resemble the following:

• Fahy and Hastie Midwifery Guardianship model in 3rd stage labour.
• The woman has been given information about, discussed and consented to birthing her placenta in a natural, mindful manner.
•  The woman is well prepared and understands that she is still in labour when the placenta is being born.
• Expectant management was defined as a ‘hands off’ policy, which involves waiting for signs of separation and allowing the placenta to delivery spontaneously.
• The woman and her baby are physically and emotionally healthy at the end of second stage.
• The woman feels that she is in a safe and supportive environment.
• The attending midwife knows how to act as a midwifery guardian.
• Both the woman and midwife are willing to utilise an exogenous oxytocics if bleeding needs to be controlled quickly
• Immediate and sustained mother and baby skin-to-skin contact
• Mother and baby are kept warm [Self-attachment breastfeeding; Upright position]
• Midwife unobtrusively observes for signs of separation of the placenta
• Placenta birthed entirely by maternal effort and gravity
• No cord traction
• No fundal meddling or massage
• Midwife gently encourages woman to be ‘present’ and mindful, to focus on baby while aware of placenta that is yet to be born Partner/support people ensure interactions remain focused on mother and baby
• What important decision needs to be made before labor has even started in order to have a physiologic third stage labor?

Factors that should be identified prior to the start of labour:

1. Discuss Medical History
2. Previous history of primary PPH[Postpartum Hemorrhage] e.g. fibroids, uterine septum, previous uterine surgery including caesarean
3. Over distended uterus e.g. due to multiple gestation, macrosomia or polyhydramnios
4. Abnormalities of the placenta e.g. low lying placenta, placenta accreta, percreta, placenta praevia
5. Antepartum haemorrhage e.g. associated with the placenta Hb of less than 110 g per litre
6. Abnormalities of coagulation e.g. due to: fetal death in utero, hypertension, clotting diseases, anti-coagulant therapy, ante-partum haemorrhage, general infections

1. Assess Environment and Ensure It Is Safe And Comfortable– Another way in which the third stage of labour can be affected by psychophysiology is the impact that birthing environment has on the autonomic nervous system and hormonal regulation. Lack of appropriate birth environment e.g. bright lights, cold temperature, noisy strangers in the room, excessive chatter and noisiness  affect oxytocin levels and can increase pain and unfavourable placenta detachment and bonding with baby. Any factor that does not allow the mother to practice mindfulness in her environment should be considered.

The mother should also be informed of the importance of the third stage of labour and how it promotes natural connection with the baby. Mention should be made of the effects of synthetic oxytocin ; how it may potentially block the release of natural oxytocin [ which helps to relax the uterus and reduces the adequate amount of hormones to maintain fear and anxiety].

1. Promoting Skin- to Skin-During the third stage of labour, the mother’s levels of oxytocin increase in response to the smell and touch of her baby; most particularly during breastfeeding. During a physiological third stage of labour, oxytocin floods the woman’s brain, triggering feelings of profound love for her infant . High levels of oxytocin spill over into the mother’s blood circulation.This hormonal response is exactly what the woman needs so that strong uterine contractions continue during third stage, enabling the placenta to be born naturally with sustained haemostasis.

1. Engaging Midwifery Guardianship- This should be carried out by a trusted midwife.

• What factors can the doula help with during labor to make sure that this is a possibility?
• Give mother handout on the benefits of a normal third stage of labour; she can review it and discuss it with her OB and midwife
• Discuss with the mother how she wants to maintain a comfortable environment in her birth plan during the third stage of labour and immediately after the medical team have completed their tasks. i.e lighting, limiting persons in the room, where the baby should be placed.
• Providing information on the importance of the third stage of labour in relation to bonding with baby and an overall positive birth experience.
• Step-by-step explaining of the events that an ideal third stage looks like so the mother can know what to expect from her body, her medical team and how she can be included in the process.
• Discuss the use of artificial oxytocin , benefits and overall effects so mother can make an informed decision of whether she consents or not
• Explaining Midwifery Guardianship and what it should and should not look like.

• What factors must the medical personal be involved with medically?

Unfortunately, clinicians are usually advised to limit third stage to 30 minutes.

Active management of third stage uses power external to the woman to deliver the placenta and achieve haemostasis. It is believed that unless the woman is fully involved in deciding what happens to her, then the use of external power can be disintegrative of her own inner power with unintended consequences, such as PPH.

Safety Considerations for a Normal Physiologic Third Stage of Labour:

• The woman has had a healthy pregnancy
• All women who (in the antenatal period) were expecting a vaginal birth
• The woman has been given information about, discussed and consented to birthing her placenta in a natural, mindful manner, including women who had many of the risk factors for PPH
• Partner/support people ensure interactions remain focused on mother and baby

The midwifery guardian’s focus is on nurturing the woman’s sense of confidence and safety through a trusting relationship within which the woman’s attitudes, values and beliefs are respected and of primary importance. Midwifery Guardianship involves guarding the woman and her birth territory so that she may labour, feeling safe and supported, without unwanted intrusions, distractions or interruptions.

A Midwifery Guardian works with the woman so that she is able to slow down her everyday thinking mind and focus mindfully on her baby, her body and the birthing process

Supporting women to find and use their own integrative power is a different activity from the obstetric concept that the woman needs to be ‘rescued’ from suffering and ‘delivered’ of her baby.

The placenta should be birthed entirely by the woman’s efforts and gravity in order for the membranes to come completely and safely off the uterine wall. A couple of DON’TS are required. In natural third stage, leave the uterus alone; DO NOT massage, or meddle with it. It is inappropriate interference in a normal placental birth because meddling with the uterus creates partial separation and bleeding. Likewise, leave the cord alone: DO NOT pull on the cord which, again, can cause partial separation and bleeding and could even invert the uncontracted uterus.

Reference: Optimising Psychophysiology In Third Stage Of Labour: Theory Applied To Practice